My 87-yr-old mom's pacemaker has a battery that is wearing out in approx. six months. She has had dementia for 7 years, and can't remember my name, but remembers I'm her oldest daughter and can hold her own in a conversation, complete with good advice. Both her primary Dr and the senior nurse at her ALF say any operation with anesthesia will cause her to lose a lot of cognitive memory and that it won't be recovered after the operation. Her pacemaker is used about one-third of the time, says her cardiologist, meaning her heart isn't totally dependent on the pacemaker.

My quandary: She's told me for years (long before her dementia really kicked in) that she felt she has lived too long. She has a living will. She has a DNR. She's not depressed - she's a very cheery person and is usually pretty happy, with a good sense of humor. But I'm concerned about doing anything to speed up her cognitive decline. I know doctors can keep people alive for a long time, but should they? Where does quality of life fit in? I'm my mother's POA and healthcare surrogate. My sibs have not helped with her care other than to visit her occasionally (well, 2 of the 3 have and they live very far away; the 3rd who lives 2 hrs away hasn't visited in almost 4 years). I haven't talked with them about this.

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Sometimes you are "prolonging death" instead of "extending life."

Based on what you have said, if I were in your shoes, HONESTLY I would not have the procedure done.

Also, do NOT discuss it with the siblings. Do NOT.
It will not end well.
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Reply to XenaJada

I’m sorry you have to make such a difficult decision. Your mom has a DNR, the pacemaker is shocking her heart back to normal rhythm every time it is needed. It’s like being resuscitated every time.
My mom has a DNR. we decided not to have a pacemaker put in for my mom (she’s 90 with Alzheimers) It was the hardest decision of my life but I know it’s the right one.
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Reply to jan135

"I know doctors can keep people alive for a long time, but should they?"

I would suggest reading "Being Mortal" by Atul Gawande before making the decision. Only because it helped me, and maybe it will help you.
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Reply to DarkSeaglass

My husband's gramma underwent the Whipple procedure for her pancreatic cancer when she was 85. She had no cognitive issues prior and no decline after. My friend's father underwent shoulder surgery in his early 70's and was never the same after. I'm not sure the cognitive impact from anesthesia is guaranteed or predictable, But have you actually asked your mom what she wishes? You say she can hold her own in a conversation but not sure what that means. It seems she has given you her pre-dementia answer (per your post). I think that's your directive.
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Reply to Geaton777

My husband had a pacemaker surgically implanted on July 4th this year......without general anaesthesia. He was given a local anaesthetic and a valium drip for twilight sleep during the procedure. Inquire with your mom's doctor about doing the same for her.

Good luck!
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Reply to lealonnie1

Don't change the battery just because it's "due". The cardiac physiologists who test it will tell you what state it's in; and anyway they don't just conk out, just like that, you should get a substantial grace period for decision-making.

Having said that, your mother is enjoying a reasonably good quality of life, isn't she? She is usually pretty happy and cheery - no pain, no anxieties, no depression? That being so, if she does need her pacemaker battery replaced to maintain her current condition you should go ahead. It shouldn't, as far as I remember, require full anaesthesia: I should check with her cardiologists whether the sedation that would normally be used carries an acceptable risk compared with the risk of not maintaining the device.

Will it help clarify things for you if you invite your siblings to voice an opinion? In my view you have no obligation to discuss this with them, but if you feel the conversation would be useful and right, that's different.
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Reply to Countrymouse

There’s always a risk with anaesthesia and quite rightly it’s been discussed with you. I agree that quality of life is far more important than length of time. It sounds like your mum feels that way too.

My uncle had had dementia and bowel cancer that had spread. I took the decision that he would be confused and unhappy in hospital having treatment and arranged pain relief palliative care . Despite being told he’d only have weeks - he enjoyed a further 15 months stress free mostly happy without medical intervention.

Do what feels right for your mum - I wish you both the best

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Reply to DareDiffer

I was 73 when I had to have a fairly lengthy surgical procedure that required general anesthesia. I was concerned about possible cognitive effects. The anesthesiologists with whom I spoke both told me that the literature now indicates that general anesthesia in the elderly, in and of itself, does not normally result in long-term cognitive decline. A more common concern is delirium, but it is usually short-lived, and decreases if the patient can be sent home soon after the surgery. Knowing that, I alerted the person who had medical POA for me, but I had no adverse effects. For a pacemaker battery, I am quite certain that general anesthesia is not required to replace it. If general anesthesia is usually used, you may ask the anesthesiology team what the alternatives might be, if you are concerned. I wouldn't accept the opinions of a nurse and a physician who is not an anesthesiologist in trying to make the decision.

The need for the battery is apparently 6 months or more away, so while exploring the options now, it probably makes sense for you to wait until the battery is definitely needed before making a final decision. Your mother's situation might change by then and make the decision clearer.
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Reply to caroli1
jacobsonbob Nov 13, 2019
Your mention of being 73 at the time makes me wonder at what point is a person considered "elderly" when discussing general anesthesia. Would a there even be such a concern in the case of a fit, healthy, mentally fully-functioning 73 y/o who is considering surgery?
The procedure is minimally invasive. The person to talk to about anesthesia and aftereffects if the one giving it - the anesthesiologist. There are several different agents that can be used. Usually cognitive issues with anesthesia are a result of loss of oxygenation to parts of the brain - blood clots or poor circulation. The anesthesia doctor is the best person to assess the risks and let you know mom's realistic outcomes.

So, schedule the procedure. Take a list of questions for all doctors. If several doctors are not giving you good chances for positive outcomes, then it might be better to let nature take its course. My bet is that mom will do fine... and I was a critical care RN for many years.
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Reply to Taarna

I wanted to thank everyone who posted an answer to my very hard question. I know we all have been in similar situations, where the options don't seem to favor one thing or another. I've taken away helpful advice from each of you, and I thank you so, so much! You've helped outline a plan of action, and that's exactly what I needed. Sending many heartfelt hugs your way...
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Reply to VofReason

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